ALS Algorithm Flashcards
1
Q
What is the advantage of using the ALS algorithm?
A
- Rx to be delievered expediently
- Without protracted discussion
2
Q
Key actions to improve survival in cardiac arrest:
A
- Early, high quality, uninterrupted chest compressions
- Early defibrillation for shockable rhythms
3
Q
What is the ALS algorithm?
A
4
Q
Recognition of cardiac arrest - Step 1:
A
- HAZARDS - Ensure the environment is safe; approach the pt.
- HELLO - Check for a response - Shake the pt’s shoulders & ask loudly: “Hello, Are you alright?”
- HELP - If they do not respond shout for help/pull the emergency buzzer & proceed to Step 2.
5
Q
Recognition of cardiac arrest - Step 2:
A
- Assess for breathing & signs of life (take ≤ 10s).
- Turn the pt. onto their back
- Open airway - head tilt & chin lift
- Determine if the pt. is breathing normally:
- LOOK - chest movement
- LISTEN - breath sounds
- FEEL - air on your cheek
- Assess for a carotid pulse simultaneously
6
Q
Recognition of cardiac arrest - Step 3 - If help has arrived:
A
- Start CPR
- Instruct the helper to the call resuscitation team (2222 if in-hospital, 999 if out-of-hospital)
- Helper to get the resuscitation equipment
7
Q
Recognition of cardiac arrest - Step 3 - If help has NOT arrived & you’re alone:
A
- Leave pt. to get help
- Get resus equipment
- Return ASAP to start CPR
8
Q
Performing CPR - Step 1:
A
- Place the heel of 1 hand in the centre of the chest with the other hand on top.
- Interlock your fingers
- Keep your arms straight
- Position shoulders vertically above the pt’s chest
- Compress to a depth of 5-6 cm.
- Allow the chest to recoil after each compression.
- Repeat at a rate of 100-120 min-1.
- Continue with a ratio of 30 chest compressions to 2 breaths
9
Q
When to change person doing compressions to avoid fatigue?
A
- Change every 2 min
10
Q
How to do compressions when airway secured/advanced airway in place?
A
- Continuous compressions wihtout pausing during ventilations
Ventilate at 10 breaths/min
11
Q
What is the role of waveform capnography during CPR?
A
- Ensuring correct ETT placement
- Monitoring ventilation rate & avoiding hyperventilation
- ID ROSC during CPR - increase in end-tidal CO2
- Prognosticate during CPR
12
Q
Monitoring during CPR:
A
- Clinical signs - breathing, eye opening, movements
- Pulse checks
- Heart rhythm
- End-tidal CO2 with waveform capnography
- Bloods - avoid finger pricks
- Invasive cardiac monitoring
- Focused US/echo
13
Q
What principles to remember during CPR?
A
- Good quality compressions
- ID & Rx reversible causes
- Secure airway
- IV access
14
Q
Performing CPR - Step 2:
A
- Attach the defibrillator ASAP
- Apply the self-adhesive pads beneath the R clavicle and the L-MAL.
- Minimise interruptions to chest compressions.
- As soon as the defibrillator is attached, perform a rhythm check.
15
Q
Rhythm assessment - How to perform Rhythm check with AED?
A
- Follow the prompts
16
Q
Rhythm assessment - How to perform Rhythm check with manual defibrillator:
A
- Pause chest compressions
- Observe the rhythm on the defibrillator screen
- Determine if shockable or non-shockable
- Take no longer than 5 s to do this
17
Q
What are the shockable rhythms?
A
- VF
- Pulseless VT
18
Q
What are the non-shockable rhythms?
A
- PEA
- Asystole
19
Q
Characteristics of VF:
A
- Bizarre, irregular waveform
- No recognisable QRS complexes
- Random frequency & amplitude
- Uncoordinated electrical activity
Exclude artefact - movement/electrical interference.
20
Q
Characteristics of pulseless VT:
A
- Broad complex rhythm
- Rapid rate
- Constant QRS morphology
check for a pulse.
21
Q
Characteristics of PEA:
A
- Clinical features of cardiac arrest
- ECG normally associated with a palpable pulse
22
Q
Conditions ass. w/ PEA:
A
- Hypovolaemia
- Tamponade
- Tension pneumothorax
- Massive PE
23
Q
Characteristics of Asystole:
A
- Absent QRS
- Atrial activity (P waves) may persist
- Rarely a straight-line trace
Completely straight line - monitoring lead disconnected
24
Q
Mx of shockable rhythms - AED:
A
- Follow the audio/visual instructions from the machine
25
Mx of shockable rhythms - **Manual defibrillator**:
1. **Apply** self-adhesive **pads** while doing compressions
2. **Pause** compressions (< 5 sec) for rhythm check
3. **Resume** **compressions** immediately
4. Warn all **rescuers** to **"stand clear"** expect one doing compressions
5. **Remove O2** as appropriate
6. **Select** the appropriate **energy** on the defibrillator
7. Press the **charge** button
8. Once charged - instruct the rescuer doing chest compressions to **"stand clear"**
9. When **all** rescuers are **clear**, deliver the **shock**
10. **After** the shock - **Immediate CPR**
11. **Do not pause** to reassess the **rhythm** or feel for a **pulse**
12. **Continue** CPR for another **2-min cycle**
13. **Continue** to repeat the 2-min CPR cycle - rhythm check - defibrillation sequence **if VF/pVT persists**
14. Prepare **ADR 1 mg** IV & **Amiodarone 300 m**g IV to be given **after 3rd shock**
15. Give **further ADR 1 mg** IV after alternate shocks (about **every 3-5 min**)
26
What shock energy is needed?
1. **1st** shock - at least **150J**
2. **Subsequent** shocks - **same** or **higher**
27
If electrical activity compatible with a pulse is seen during a rhythm check, or the AED advises no shock is required or check for signs of life - If **no** signs of life are present:
1. Continue **CPR**
2. **Switch** to the **non-shockable side** of the algorithm.
28
If electrical activity compatible with a pulse is seen during a rhythm check, or the AED advises no shock is required or check for signs of life - If **signs of life are present**:
1. Start post-resuscitation care.
29
Mx of non-shockable rhythms - AED:
| If the AED advises no shock is required?
1. **Follow** its **prompts**
2. Continue **CPR**.
30
Mx of non-shockable rhythms - Manual Defibrillator:
If electrical activity compatible with a pulse is seen, check for a pulse and/or signs of life.
If **no pulse and/or signs of life**:
1. Continue **CPR**
2. Prepare **ADR 1 mg** IV/IO to be given as soon as access is achieved
3. **After 2-minutes** of CPR, pause chest compressions briefly for **rhythm check**
31
If an organised rhythm is seen during a 2 min period of CPR - What to do?
1. **DO NOT interrupt compressions** to palpate pulse
2. **Only stop** compressions to palpate pulse **when signs of life**
32
If there is any doubt when doing pulse check - what to do?
1.Continue CPR
33
Sites for IO access in adults?
1. Proximal humerus
2. Proximal tibia
3. Distal tibia
34
How to give drugs peripherally during CPR?
1. **Flush** with 20 ml of fluid
2. **Elevate extremity** for 10-20 sec
35
Mx of non-shockable rhythms - Manual Defibrillator:
If electrical activity compatible with a pulse is seen, check for a pulse and/or signs of life.
If **VF/pVT is seen** at the rhythm check, **or the AED advises** to deliver a **shock**:
1. **Switch** to the **shockable** side of algorithm
36
Reversible causes of cardiac arrest - 4 Hs and 4 Ts
**4Hs:**
1. Hypoxia
2. Hypovolaemia
3. Hypothermia
4. HypoK/ hyperK/ hypoglycaemia/ hypoCa/ H ion excess (acidaemia)
**4Ts:**
1. Thrombosis - coronary / PE
2. Tamponade
3. Tension pneumothorax
4. Toxins
37
Rx - Hypoxia:
1. Ensure **airway** is **patent**
2. **Ventilate** the lungs using a self-inflating bag;
3. Give **high-flow 100% O2**
4. **Don't hyperventilate** - reduces the coronary perfusion pressure and can worsen the outcome
38
Rx - Hypovolaemia:
1. IVF
2. Blood
39
Rx - Hypo/HyperK:
1. HyperK - give calcium chloride followed by insulin/dextrose infusion.
2. HypoK - replace
40
Rx - Hypothermia:
1. Active re-warming techniques
2. Cardiopulmonary bypass may be considered
41
Rx - Coronary Thrombosis:
1. PCI
2. Thrombolysis
42
What is the commonest cause of thromboembolic or mechanical circulatory obstruction?
1. Massive PE
43
Rx - Pulmonary Thrombosis:
1. Fibrinolysis
44
Rx - Tamponade:
1. Needle pericardiocentesis or resuscitative thoracotomy
45
Rx - Toxin OD (inpatients):
1. R/V of the pt's drug chart may be helpful
46
Rx - Tension Pneumothorax:
1. Early needle decompression (thoracocentesis)
2. Followed by chest drain insertion is needed.
47
Signs of ROSC:
1. **Clinical** - breathing, eye opening, movements
2. **Monitoring** - sudden increase end-tidal CO2 or arterial BP waveform
48
What to do after Return of spontaneous circulation (ROSC)?
1. **Reasses** pt. using **ABCDE** approach
2. Aim for **sats** of **94-98%**
3. Aim for a **normal PaCO2**
4. 12-lead **ECG**
5. **Rx** any precipitating **cause**(s)
6. Consider targeted **temp Mx**
49
Who should be the one discussing stopping CPR?
1. Team leader
50
How to Dx death after unsuccessful resus attempt?
1. **Observe** pt. for **5 min** after stopping CPR
2. **Absent mechanical cardiac Fx** - Absent central pulse / absent heart sounds
3. **Absent reflexes** - pupillary / corneal/ motor response to supra-orbital pressure
4. **Supplementary features** - Asystole on ECG/ absent flow on direct intra-arterial pressure monitor (A-line) / absent heart contractions on echo
51
Post resus event tasks to do:
1. Ongoing **care** of **pt.**
2. **Documentation** of resus
3. **Communication** w/ **relatives**
4. Post-resus **debriefing** - immediate & delayed
5. **Restock** equipment & drugs
6. **Audit** forms
